1, __________________ (State Your Role), residing at ________________________, being first duly sworn, state as follows:
I am the _____________________ (Your Role) of the Estate of ___________________ (“Decedent”) who died on ____________ (“Date of Death”).
At the time of death, the Decedent's domicile was _____________________________, and the Decedent had resided in the State of ___________________ and was not a resident of any other state of the United States at the time of death.
The Decedent did not claim any state of domicile other than the State of _____________
on any instrument or Will executed within the two years prior to death.
Certificate(s) representing ___________________ were physically located in ________, at the time of the Decedent's death.
Maker of Affidavit
Subscribed and sworn to before me this __ day of ________, 20__.
My Commission Expires on: ______________